At RSNA, Imaging Informatics Sage Joe Marion Offers Straight Talk on this Moment in Imaging IT

Industry observer Joe Marion shares his insights on the path forward into the imaging informatics future

Joe Marion, a principal in the Waukesha, Wis.-based Healthcare Integration Strategies LLC, has participated in 42 RSNA Conferences—probably among the most of any current attendee. No one has a broader perspective on the imaging informatics vendor market than Marion, who spent years on the vendor side before shifting over to consulting a number of years ago.

As in recent past years, Marion sat down at this year’s RSNA Annual Conference, being held at Chicago’s vast McCormick Place Convention Center, and sponsored by the Oak Brook, Ill.-based Radiological Society of North America, on Tuesday afternoon, to speak with Healthcare Informatics Editor-in-Chief Mark Hagland. Below are excerpts from that interview.

What’s your overall impression of the exhibit floor at this year’s RSNA?

Well, obviously, the one buzzword that’s everywhere is artificial intelligence. The reality is that I think it means different things to different people. The difference between last year and this year is that some things are coming to fruition; it’s more real. And so some vendors are offering viable solutions. The message I’m hearing from vendors this year is, I have this platform, and if a third party wants to develop an application or I develop an application, or even an academic institution develops a solution, I can run it on my platform. They’re trying to become as vendor-agnostic as possible.

Joe Marion

Meanwhile, outside of one vendor, I’m not really seeing a whole lot of emphasis this year on value-based care; that’s disappointing. I don’t know whether people don’t get it or not about value-based care, but the vendors are clearly more focused on AI right now. And that’s surprising to me in terms of some of the mandates, for example, for referring physicians to soon use clinical decision support—that’s important. [Here, Marion referred to the Protecting Access to Medicare Act (PAMA), which requires referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services—CT, MR, nuclear medicine and PET—for Medicare patients. The federal Centers for Medicare and Medicaid Services (CMS) will progress with a phased rollout of the CDS mandate, as the American College of Radiology (ACR) explains on its website, with voluntary reporting of the use of AUC taking place until December 2019, and mandatory reporting beginning in January 2020.] And I don’t think the imaging marketplace is anywhere prepared to manage value-based care yet.

Meanwhile, we’re seeing ongoing consolidation among vendors: for example, Intelerad has just acquired Clario. [As announced on Nov. 25 in a press release published on Business Wire, the Montreal-based “Intelerad Medical Systems™, a leader in enterprise workflow solutions, today announced the acquisition of Clario Medical, a zero footprint worklist company based in Seattle, Washington. The combined product offering will augment Intelerad's robust and highly scalable enterprise imaging solutions with Clario's rich, zero footprint worklist, satisfying the demanding needs of rapidly growing radiology practices and health systems.”] Clario was the last remaining independent worklist management/workflow company. Medicalis and Primordial had been the last two others, before being acquired by Siemens and Nuance, respectively. So all of that independent workflow capability is gone. But people perceive that even though Medicalis is now a part of Siemens and Primordial is a part of Nuance, that they’re available for third-party applications. They’re viewed as vendor-agnostic solutions, even though they’re part of bigger companies.

Probably not. The only real reasons now that people are purchasing PACS systems any longer are replacement or upgrade. The one that’s on fire has been Visage [the Richmond, Victoria, Australia-based Visage Imaging]; they picked up Mayo Clinic last year and so everything in all of Mayo is now running off Visage. They’ve replaced their legacy GE and Siemens systems. They’ve just announced Partners in Massachusetts. So they’re on a roll.

Why is that?

I think people like their product, it’s scalable, and they’ve got a great user interface. It’s a viewing environment, not a complete PACS. They rely on third parties for the archive. They don’t address the vendor-neutral archive, they’re just about the front-end viewing. And they use third parties like Primordial or Medicalis for workflow, and just focus on the viewing aspect.

The other one that’s on fire is Sectra [the Linköping, Sweden-based Sectra AB]. Philips used them for PACS over ten years ago, and when they bought Stentor, they dropped that relationship. But only half of the sites that had Sectra went with Philips, half stayed with Sectra. And they’ve picked up HAP [the University of Pennsylvania Health System] in Philadelphia, and City of Hope in California. They never used to get invited to the table for the big deals. And the University Hospitals in Cleveland is their showcase. And now that they’ve got some of those big university hospitals, for PACS, they’re getting other deals.

So we’re seeing changes in the lead [PACS] vendors in some cases. Visage is a clear example because they’ve had so much success; Sectra is up and coming—they’ve always been strong in mammography, and they’re leveraging a lot of that technology now. Change Healthcare had some issues in terms of that transition from McKesson to change. They haven’t kept pace; but I think they can easily recover. They’re moving, interestingly enough from their dedicated relationships, and they have a relationship with Google and are going exclusively with Google Cloud, so over the next few years, their product line will change considerably. The same is true with Intelerad: they’re pushing heavily into cloud structure, which is why they acquired Clario. IBM has gotten more realistic. They do have a couple of pieces out there that are current, release product. Last year, it was a lot of smoke and mirrors and promises; this year, they legitimately have some products out there.

The fact is that tTe AI market today is like what the PACS market was fifteen years ago—very crowded. There are something like 50 players out there; it will shake out over the next several years.

What will make some succeed and some not?

I think it’s going to be the value of the product, and also the extent to which the vendors will make their products flexible in terms of being interfaced with others, so there’s this integration aspect, folding into vendor A, vendor B, vendor C, etc. So for a third party, the more they reach out and create relationships, the more successful they’ll be. A lot of it will come down to clinical value, though. Watson has had problems in that people have said, it’s great, but where’s the clinical value? So the ones that succeed will be the ones that find the most clinical value.

This is your forty-second RSNA. When you look at the trajectory of last ten years and what’s ahead, what do you see happening in the next few years?

I think the first push of AI right now is in the context that some vendors have described it as enabling the radiologists to become more efficient. That’s the primary, initial set of tools. But that’s the clinical set of tools. The next wave will go beyond the clinical to the operational, making the department more efficient, and being supportive of value-based care.

What should healthcare IT leaders be focused on right now, as they look at this market?

Well, the other aspect of this is that more and more of this technology, on the imaging side, is moving to the cloud. And that’s part of the struggle of this: how are they going to manage that, in terms of security and all the other issues they worry about, while maintaining ownership of their data?

Are there any dangers or cautions for IT leaders to consider in the next few years?

I think the challenge lies in asking how much to focus on the EHR [electronic health record], versus how much to focus on other areas. Some of these cardiology solutions are reporting modules. Cardiology has looked unfavorably on cardiology PACS systems, because they haven’t proven to be full-fledged cardiovascular information systems. Many providers have tried to make cardiology PACS systems work as full cardiovascular information systems. For example, one major EHR system has a cardiology solution that just collects data, but doesn’t manage the images. So the IT people think they’ve got a solution, but from the standpoint of cardiologists, they don’t; it’s not robust enough to serve all their needs. And cardiology has come out of disparate systems, EKG, vascular, ultrasound, a hodgepodge of systems, and no single environment. And over the last ten years, those have evolved to provide a true cardiovascular IS. GE’s done that, Fuji’s been transitioning to that. Lumedx [the Oakland, Calif.-based Lumedx] really has proven itself to be the gold standard in that area; they started with the databases, and then expanded off that to do the reporting; they do the registries. So they have full-service capability. They acquired a PACS vendor. They have a relationship with a vendor for the hemodynamic data.

On a scale of 1 to 10 in terms of optimism versus pessimism, in terms of imaging informatics moving forward to where it needs to go, where would you say you are right now?

I guess I’d say maybe a “6.” One of the things I’ve done is to create a schematic that I’ve been sharing with vendor executives this year on the exhibit floor. It has to do with the integration of various capabilities. On the one hand, you’ve got one set of capabilities that are fairly well established—the modalities, PACS, RIS [radiology information systems], EHRs, and advanced visualization. Then you’ve got emerging capabilities, including analytics, AI, workflow orchestration, CDS [clinical decision support], and referral management. How will vendors integrate all of those capabilities on behalf of their customers?

Every vendor has a slightly different strategy. But for them to succeed, they’ll have to figure out a strategy to enable them to do all of those things, either by themselves or through others. And even as far back as the modalities, people are starting to build AI into the modality. For example the patient moved [residences]; what do I do. Do I have to repeat images or not?

Ultimately, then, vendors will have to move towards a new level of robustness?

Yes, they’ll have to figure all of this out in terms of a changing customer mix. So Advocate [the Downers Grove, Ill.-based Advocate Health Care] and Aurora [the Milwaukee, Wis.-based Aurora Health Care] are now together, for example [on April 2, the two systems merged into a 27-hospital, $11-billion-in-revenues integrated health system, the tenth-largest in the U.S.] And they’re working off two different Epic EHR systems. Advocate concentrated on GE for PACS; Aurora is focused on McKesson/Change for PACS. So how will they contend with that and move forward? If you think of the workflow, why shouldn’t a radiologist sitting in Milwaukee be able to read a case down in Chicago? So because of consolidation, it’s a different picture than five years ago. So the workflow orchestration element is huge. How do I now divvy up that work between Advocate and Aurora? How do I provide the information from the EHR that accompanies the images, to make that information available? The vendors are wrestling with this. They haven’t yet realized that their customer base has changed.

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Supporting an evolving, complex technology stack along with the needs of both internal and external customers is not easy for IT vendors. Moving forward, emerging technologies, such as automation and artificial intelligence (AI) will redesign the way in which tech support firms function, according to a Black Book Research survey.

As a result of new and emerging technologies, support operations will look significantly changed from what exists in 2018, according to the research report.

“IT support will become much more customer-facing, but also much more robotic,” Doug Brown, Black Book Research managing partner, said in a statement. “The power of automation and the rise of the patient experience are disrupting an idling tech support sector as vendors restate relevance in the client services space.”

AI, chatbots and other forms of automation are now grabbing attention within most of the systems targeted at the healthcare IT support industry, but there's not a lot of companies employing them, according to Black Book’s research. Only 3 percent of healthcare providers and 5 percent of payers responding to the Black Book survey have launched automated client service strategies.

“Healthcare tech support is on the cusp of change and as healthcare technologies evolve and improve, they are likely to reshape the very nature of what is client services and tech support,” Brown stated.

With innovations like AI-powered conversation platforms, tackling challenges in natural language understanding and context resolution, healthcare tech support firms will be able to create advanced virtual agents that retain deep knowledge about supported products.

“Clients will be able to provide end users with a new way of interacting with support services beyond the help desk,” Brown said.

There also is a shift from an exclusively internal focus to an external focus, as delivering and support a superb customer experience is becoming the primary driver of competitive advantage for healthcare organizations.

"As technology becomes more profoundly entrenched into every turn of the healthcare consumer journey, vendors are also beginning to realize that the traditional internally-focused support organization may be best suited to help their provider clients successfully shift their focus to consumers,” Brown said.

Eighty-eight percent of CIO respondents reveal they are beginning to re-imagine the role of the support organization as they recognize technology is now critical to the patient experience and that their existing support teams are not well positioned to provide the best support, the survey findings indicate.

Blockchain, which offers a shared, distributed, and decentralized ledger that serves as a foundation for trusted collaboration among multiple parties throughout the tech support processes, also will play a role in this area. The next wave of innovations will be focusing on standardizing blockchain solutions that can be seamlessly integrated with organizations' IT systems to jointly drive the tech support ecosystem, according to Black Book Research.

The increasing role of Big Data and the Internet of Medical Things also will fundamentally change the technology support functions. Healthcare organizations are growing increasingly dependent on big data direct their initiatives. This tsunami of data requires more computing power, more hardware, more network capacity and more devices, both traditional and mobile, along with the need for ongoing maintenance of cloud infrastructure, servers, desktops, laptops and storage and network devices, according to the report. This will require IT vendors and managed services providers to have a deep pool of skilled subject matter experts available to proficiently service clients and also maintain the certifications to support multiple manufacturers' hardware, storage devices, operating systems, and networks.

With regard to IoT devices, as this technology expands to meet the needs of the industry, service desk teams are given the opportunity to specialize and research better ways to manage these devices and ensure they are under their control, and return value, and not risk to any environment.

More sophisticated tech support also will be necessary to support enhance patient care, according to the research. Eighty-eight percent of clinicians responding to the survey assert their delivery of patient care services are continually impeded by subpar user tech support, increasing nearly ten percent from last year's survey. Ninety percent of hospital chief medical officers surveyed asserted multi-level tech support from their health records vendor ranging from help desk through engineering interventions will be a leading competitive inpatient electronic health record (EHR) differentiator in 2019.

Of the 92 percent of hospital respondents that view high quality user support as a make or break feature in a vendor relationship, 60 percent say their tech support (both EHR firm provided and from EHR tech support outsourcing partners) are currently falling short in their responsibilities to ultimately allow patient care improvements through well trained delivery personnel.

Eighty-three percent of hospital tech managers prefer that their EHR deliver direct, comprehensive tech support, not push the responsibility to third parties or on the hospital system itself as the only options. Eighty-one percent of those clients employing third party outsourcing tech support are significantly dissatisfied with the level of response and the quality of their services in the twelve months following go-live. Clients could potentially be leveraging one vendor for their help desk services and another for their upgrade services and so on which can lead to an overall disparate support strategy, according to the report.

“The increasing complexity of healthcare technology has made it even harder for an in-house help desk team, especially in small and medium sized communities to have sufficient expertise to meet all of an organizations' tech support needs,” Brown said.

Enterprise tech support is a highly complex and niche area in healthcare, where specialists can make a big difference in client loyalty by catering from Level 1 to Level 4 product support to ensure all the provider's business goals are aligned with technology readiness.

Vendors scoring highest among the four comprehensive levels of technical support are Cerner, Allscripts and MEDITECH. The majority (84 percent) of tech support for Epic clients were attributed to third party outsourcers, consultants, and independent tech support firms working in Epic Systems client facilities.

Today wraps up the 104th annual Radiological Society of North America (RSNA – www.RSNA.org) meeting.Mother Nature made it a challenging place to get to early in the week, but from all accounts, attendance was on par with the past few years.

From an imaging informatics perspective, this year saw a number of things that point to a resurgence in imaging.It also presented some disappointment with respect to how the imaging vendors are dealing with a changing healthcare environment.

Artificial Intelligence – the obvious

Let’s begin with the 600-pound gorilla in the room, and that would be Artificial Intelligence (AI).By all accounts, if you were to sum up this year’s meeting, AI everywhere would be how one would describe it!AI has been a topic of discussion for several years now, initially driven by IBM’s Watson Health initiative.

In prior years, there was considerable talk about how AI was going to revolutionize Radiology, and potentially replace the radiologist.This year, the emphasis seemed to really shift from the “pie-in-the-sky” discussion to real-world, commercially available solutions.

A key development conundrum has been how to commercialize AI.Academic centers represent a first line of research into AI applications, while “boutique” companies have struggled with how to get developments to market.Large imaging informatics companies have likewise wrestled with how to approach bringing AI applications to market.The solution prevalent this year seems to be for both large and small companies to offer a “platform” for the implementation of AI.By supporting such capabilities as software development toolkits (SDK’s), vendors are providing a means for commercialization of academic and third-party applications without themselves reinventing the wheel.

The AI “store” borrows from the way smart-phone applications have evolved by providing the infrastructure for the validation and distribution of AI applications.What is not yet clear is the liability of providing access to other entity’s applications.Is the Store vendor responsible for the application, or the developer?Who files for and secures FDA approval?Given that the objective is for these external applications to interoperate with the vendor’s imaging informatics system, there is some development risk on the part of the distributing company, and potentially a shared liability as well.Only time will tell how effective this strategy is.

Depending on who you ask, AI primarily is perceived as clinical tools to improve the radiologist’s interpretation efficiency, not as a replacement to the radiologist from a clinical perspective.Conversely, there were a number of applications that make use of AI technology to enhance the way information is handled and presented, and the way it impacts the decision process.Much of this revolves around the way information is collected and made available to the clinician, such as retrieving relevant lab and other study information.

One interesting example might be Siemens Healthineers’ Proactive Follow-up application (https://usa.healthcare.siemens.com/healthineers-population-health-management/value-based-care/proactive-follow-up-for-incidental-findings).It uses natural language processing to identify incidents of follow-up, such as “repeat CT exam in six months.”Incidents requiring follow-up are summarized in a “dashboard” presentation to enhance the ability of imaging services to coordinate with the necessary clinical services to ensure that the follow-up recommendation is followed through.While not as “sexy” as an AI image processing algorithm, it may have just as much if not more impact on imaging services’ efficiency.

AI will influence imaging in another way by fostering greater use of the cloud. To maximize availability and accessibility, the cloud appears to be the major means for the deployment of AI applications. Some vendors are also increasingly moving to the cloud for their entire enterprise imaging informatics applications. Such non-traditional players as Intel and Google are becoming a greater factor in terms of how imaging is secured and managed, and AI appears to be an influencing factor.

Clinical Decision Support – the not so obvious

While major emphasis was on AI, less emphasis seems to have been given to Clinical Decision Support, and the associated mandates.The Protecting Access to Medicare Act of 2014 (PAMA) originally directed CMS (Centers for Medicare and Medicaid Services) to require Appropriate Use Criteria (AUC) consultation for Advanced Diagnostic Imaging procedures beginning Jan 1, 2017.The mandate has now been delayed to January 1, 2020, which isn’t that far away!

Imaging companies correctly point out that clinical decision support will be more a function of the electronic health record (EHR) system, and they don’t seem to be particularly concerned with how it will impact imaging applications, with a few notable exceptions.Change Healthcare (https://www.changehealthcare.com/) has been reformulated over the past few years from a “back office” services company to one encompassing imaging through the acquisition of McKesson’s imaging business.More recently, Change acquired National Decision Support Company (http://nationaldecisionsupport.com/) to address the PAMA mandates by means of synergy between its product lines.

Similarly, Siemens Healthineers acquired Medicalis, which was also focused on clinical decision support tools.Collectively, these two vendors seem most aggressive in addressing the intersection of imaging services and the changing landscape of healthcare management.

Part of this conundrum may be the perception that much of the informatics needed to address value-based care will be encompassed within the EHR.On the other hand, imaging vendors seem to be more focused on the “mechanics” as opposed to the topic of value-based care.For example, analytics tools and intelligent worklists are mechanisms that will help enable radiology to support value-based care, but they are not necessarily emphasized as such.

Consolidation and New Players

The industry continues to be a study in competitive dynamics, in that certain segments demonstrate further consolidation, while other segments continue to expand.The area of workflow orchestration has seen a transition from “incubator” companies such as Clario, Primordial, and Medicalis to complete absorption by large imaging vendors.Siemens Healthineers previously acquired Medicalis, and Nuance acquired Primordial.The surprise announcement at this year’s meeting was the acquisition of Clario by Intelerad (https://www.intelerad.com/en/press-releases/intelerad-medical-systems-acquires-clario-medical/).This now means all three of the key workflow orchestration vendors are part of larger imaging informatics organizations, and can leverage those capabilities as part of their offerings.

For a number of years, the imaging industry has lived in the shadow of the EHR, as providers scrambled to address government mandates for electronic health records.Now that much of that infrastructure is in place, it appears that imaging informatics may be well-positioned to capitalize on further investment to support the EHR.AI appears to be the first recipient of that emphasis.From my vantage point, there will need to be a further shift to emphasize applications and solutions that support consolidation and value-based care trends.It will be intriguing to see if these areas receive more emphasis at RSNA 2019!

In many ways, emergency physicians across the country are at the front lines of the battle against opioid abuse and addiction, as patients who are abusing or addicted to opioids are frequent users of emergency care.

The ED is often a hospital “entry point” for addicted patients, who present in the ED asking for prescription opioids to manage pain, or patients who are overdosing may arrive for treatment or are experiencing related crises. A significant challenge facing the healthcare industry in trying to combat opioid addiction is the lack of real-time information available at the point of care to alert emergency physicians about a patient’s medication use and history of ED visits.

Armed with real-time information about patients’ and their opioid use, physicians can provide referrals for substance abuse treatment or case management, rather than duplicating medical tests performed at another hospital. Tied in with the issue of opioid addiction, but also separate from it, excessive use of ED care is an ongoing problem facing hospitals and health systems as high users of ED care often have underlying social, mental or substance abuse problems that require care coordination and healthcare services provided outside of a hospital.

Healthcare leaders in Texas recently took steps to address many of these challenges facing hospital ED care teams by working with Salt Lake City-based company Collective Medical to give care teams throughout the state access to the Collective network and care coordination platform. The Texas Hospital Association (THA), which represents more than 85 percent of the state’s acute care hospitals and healthcare systems, or about 486 organizations, announced a partnership with Collective Medical back in May that will enable ED care teams in member hospitals to have access to an information exchange for more actionable information at the point of care.

While Texas is not the hardest-hit state in the opioid epidemic, the number of people in Texas dying from an overdose of opioids continues to grow. In 2016, there were 1,375 opioid-related overdose deaths­­­ in Texas, a rate of 4.9 deaths per 100,000 persons compared to the national rate of 13.3 deaths per 100,000 persons, according to the National Institute on Drug Abuse.

According to Collective Medical, the Emergency Department Information Exchange (EDie) platform will enable care teams in Texas hospitals to more rapidly identify complex patients in real-time with notifications and actionable care plan information. Through the platform, which integrates with electronic health record (EHR) systems, providers also gain insights into their patients, such as prior ED utilization, social determinants, prescription histories and advanced directives, which enables provide to make informed decisions regarding medically unnecessary admissions and readmissions.

“Collective is proven to improve patient outcomes in states across the country, and it is an invaluable tool for hospitals combating the opioid epidemic,” Ted Shaw, THA president and CEO, says. Shaw adds that deploying the Collective platform is just the first step to connecting all the caregivers at various point in the continuum of care. “We want to make sure that whether it be in the ER, or in the outpatient setting, within the hospital or between two hospitals, that there is a connectivity that results in actionable information, that sends alerts, and puts information in front of caregivers that allows them to make informed decisions.”

The partnership also supports THA’s recent voluntary guidelines for hospital ED prescribers of opioids, Shaw says. “One challenge with the opioid crisis in Texas is the need to capture information and look at the prescribing patterns out there, and then share that information appropriately in a HIPAA compliant fashion. This system is one that would do that,” he says.

Heather Marshall, M.D., a Texas-based ED physician and president of the Southwest Region for Alteon Health, a physician-led company that provides management and ED staffing services for hospitals, says the technology platform has been a “gamechanger” for ED clinicians in organizations where it’s been deployed.

When ER clinicians have access to real-time information about their patients, including medical histories, ER visits and prescriptions, it enables clinicians to provide better patient care and creates more operational efficiency, Marshall notes. “Instead of taking me two hours to figure out what’s going on with the patient, I have the information in 15 minutes. We can then provide the appropriate care to the patients, and by turning patients more quickly, we create operational efficiency as we can care for more patients.”

She continues, “We have people who have opioid problems and are simply accessing ER departments in good faith because they are not feeling well, but the solution to their problems isn’t necessarily that they need another CT scan, the solution to their problem is that they need treatment and they need to deal with the underlying disorder,” she says, noting that the ED network is a “win for everybody.” We get better operational efficiency when we’re not having to repeat workups and we’re able to get patients follow-up care.”

Marshall recently moved to Houston, but also currently continues to practice emergency medicine in New Mexico, where she previously lived. Marshall is familiar with Collective Medical’s ED network and care coordination platform as a result of her previous emergency medicine work both in New Mexico and in Washington State, where the technology has been deployed. The benefits of the Collective network also havespread by word-of-mouth among ED physicians.

About 10 years ago, many practicing clinicians in Seattle hospitals were recognizing the growing problem of opioid abuse and overdoses, according to Marshall. “Many of the practicing clinicians had identified issues with care coordination and lack of interoperability between EHRs. We felt it day-to-day, but we didn’t have data to move things. In 2007, the levers shifted, and we were able to identify that we had a health emergency on our hands and we needed a different set of tools,” Marshall says.

Several hospital ER departments in Seattle initially piloted Collective Medical’s EDie platform, and the platform was then rolled out across most of the state as part of a statewide collaborative effort to address overutilization of ED services. That effort was spearheaded by the Washington State American College of Emergency Physicians, the Washington State Medical Association and the Washington State Hospital Association. The initiative, called “ER is for Emergencies,” deployed seven best practices, one of which centered on interoperable health information exchange. As part of that effort, the collaboration engaged with Collective Medical to deploy its EDie technology. Other best practices focused on development of patient care plans, participating in prescription monitoring programs and patient education on appropriate ED use, Marshall notes.

According to a Brookings Institute study of the Washington State “ER is for Emergencies” program, the state saved $34 million in emergency department costs and Medicaid ED visits declined 10 percent in its first year of use in 2013. Likewise, care teams across the state have reduced opioid prescriptions coming out of the ED by 24 percent since the program’s inception.

A similar effort was rolled out in in the state of New Mexico in 2016 through a collaboration between the New Mexico Hospital Association, UnitedHealth Group, Molina Healthcare, Blue Cross Blue Shield and Presbyterian Healthcare Services. Collective Medical is currently partnered with more than a dozen state hospital associations and more than 550 hospitals in 13 states, from Alaska to Massachusetts, have deployed the company’s software and have joined the ED network. The technology platform is endorsed as a best practice for emergency medicine by the American College of Emergency Physicians.

According to Collective Medical, use of the network has improved care collaboration in healthcare organizations across the country. CHI St. Anthony’s Hospital, a critical access hospital located in Pendleton, Oregon, was able to reduce unnecessary ED visits from identified frequent ED users from 17 percent of overall visits to nine percent within six months of implementing the Collective platform. Within one year, the hospital reduced narcotic prepack prescriptions coming out of the ED by 60 percent and realized hospital cost savings of $200,000, the company says.

Even with widespread use of EHRs and health information exchanges (HIEs), Marshall says there are often gaps in real-time information about a patient’s medical history and a technology solution, such as the Collective Medical platform, can help to fill those gaps

“It’s a difference between push and pull,” she says, noting that an ER physician typically needs to have a concern about a patient or a suspicion that a patient has recently been to another ER in order to query the EHR or HIE. “You’re really dependent on making a judgment about a patient or them disclosing information. That’s a pull; I have to go and ask for information,” she says. “What Collective Medical Technologies is doing is their system is a push system. Every state or organization sets the trigger threshold for what they are looking for. The ER doctors can set the trigger threshold so that if a patient has been to a local ER, let’s say five or six times in the last 12 months, the system pushes that notification to the physician.”

A Collective Effort to Combat the Opioid Crisis

There are efforts at the hospital, community, state and federal level to address the growing problem of opioid misuse, abuse and addiction. Last week, the U.S. Senate passed The Opioid Crisis Response Act of 2018, which includes numerous important health IT provisions. The House passed its version of the legislation in June, and a committee to reconcile the differences between the two is nearing a resolution.

While the opioid crisis has gained attention in the past few years, Marshall says the problem of opioid abuse and addiction has been building for two decades. “When I was in medical school from 1996 to 2000, all the teaching to nurses and physicians was that we don’t treat pain enough. The entirety of the subject matter on this was more pain treatment, and for some reason, we locked ourselves into thinking that only meant opioids,” she says. “It’s become pretty clear to me that what I was taught in medical school has created a new set of problems, and we didn’t have a good handle on how to treat that problem.”

She continued, “We’ve learned that even giving three or four days of scheduled narcotics can change the patient’s body chemistry such that they develop some tolerance. If I’m a treating clinician, and I suddenly have information that tells me that the injury that this patient has is an old injury, not a new injury, that might change the medicine that I prescribe that day.”

Marshall also notes that there is growing support in the medical community for the application of universal precautions to patients being considered for or treated with opioid therapy for chronic pain. The concept of universal precautions has its origins in infectious diseases, such as wearing gloves when handling blood products. “The idea is that we should be using universal precautions every time we prescribe opioids. Every person that I prescribe an opioid to has a risk for addiction. As an ER physician, I don’t have time to do the level of analysis to determine that person’s risk. So, you can give a patient two pills, and then have them follow up with a primary care doctor a pain management specialist who can determine the co-morbidities for addiction dependence or medication misuse,” she says.

And, Marshall notes that the work to address today’s opioid epidemic will be a long-term effort. “It’s going to takes us 15 to 20 years to catch up to the addiction that has developed over the last 20 years. But, if we start doing the right things now, we’re going to see the benefit in 10 to 15 years,” she says.